Carpal Tunnel Syndrome Caused by a Juxta-articular Myxoma: A Case Report.

Juxta-articular myxoma (JAM) is a rare soft tissue tumour predominantly composed of mucinous tissue and usually found around large joints. We report a 73-year-old woman with a 5-year history of a soft tissue mass in the thenar eminence of the right wrist who presented to our department. An initial diagnosis of a ganglion cyst was made using magnetic resonance imaging (MRI) and the jellied content of the mass by aspiration. Two years after presentation, surgical treatment with tumour resection and carpal tunnel release via the radial approach was performed because the symptoms of carpal tunnel syndrome worsened, and the tumour invaded the carpal tunnel. Histopathological examination revealed a JAM. At the 1-year follow-up, the symptoms of carpal tunnel syndrome had resolved, and no recurrence was confirmed by MRI. Level of Evidence: Level V (Therapeutic).

Efectividad de una aplicación de telerrehabilitación para tableta en pacientes con fractura de extremo distal del radio / Effectiveness of a tablet telerehabilitation application in patients with distal radius fracture

Introducción: Evaluar si, en pacientes con fractura de extremo distal del radio, los ejercicios domiciliarios realizados en una pantalla táctil de dispositivos tableta reducen el consumo de recursos presenciales y mejoran la recuperación clínica, comparado con el programa convencional de ejercicios domiciliarios prescrito en papel. Material y métodos: Ensayo clínico pragmático, multicéntrico, paralelo, de dos grupos y controlado, con evaluador cegado y análisis por intención de tratar. Reclutados cuarenta y seis pacientes con fractura de extremo distal del radio en dos hospitales del Sistema Sanitario Público de Andalucía (SSPA). Los participantes de los grupos experimental y control recibieron el mismo tratamiento de sesiones presenciales de fisioterapia. El grupo experimental recibió un programa de ejercicios domiciliario utilizando la aplicación para tableta ReHand y el grupo control recibió un programa de ejercicios domiciliario en papel. Variable principal: número de sesiones de fisioterapia registradas en la base de datos electrónica del SSPA. Variables secundarias: número de consultas de rehabilitación presenciales con un médico rehabilitador y variables clínicas como la funcionalidad, la fuerza de prensión, la destreza manual, el dolor y la amplitud de movimiento. Resultados: El grupo experimental necesitó menos sesiones de fisioterapia (DM: −16,94; IC del 95%: −32,5 a −1,38) y consultas de rehabilitación (DM: −1,7; IC del 95%: −3,39 a −0,02) en comparación con el grupo control. Conclusión: En pacientes con fractura de extremo distal del radio, la prescripción de ejercicios realizados en una pantalla táctil de dispositivos tipo tableta a través de ReHand redujo el número de sesiones de fisioterapia y de consultas de rehabilitación.(AU)

Introduction: To assess whether, in patients with distal radius fracture feedback-guided exercises performed on a tablet touchscreen reduce healthcare usage and improve clinical recovery, more than the conventional home exercise program prescribed on paper. Material and methods: A multicentre, parallel, two-group, pragmatic, controlled trial with assessor blinding and intention-to-treat analysis. Forty-six patients with distal radius fracture were recruited in Andalusian Public Health System. Participants in the experimental and control groups received the same in-patient physiotherapy sessions. Experimental group received a home exercise program using the ReHand tablet application and control group received an evidence-based home exercise program on paper. The primary outcome was the number of physiotherapy sessions tallied from hospitals data management system. Secondary outcomes included: the face-to-face rehabilitation consultations with a physiatrist, and clinical outcomes such as functional ability, grip strength, dexterity, pain intensity and range of motion. Results: The experimental group required fewer physiotherapy sessions (MD: −16.94; 95%CI: −32.5 to −1.38) and rehabilitation consultations (MD: −1.7; 95%CI: −3.39 to −0.02) compared to the control group. Conclusions: In patients with distal radius fracture, prescribing feedback-guided exercises performed on a tablet touchscreen provided by ReHand reduced number of physiotherapy sessions and rehabilitation consultations.(AU)

[Short-term clinical efficacy observation of lesion removal, bone graft fusion, and external brace treatment for late-stage wrist tuberculosis].

OBJECTIVE: To observe the clinical efficacy of lesion removal, bone grafting, fusion, and external fixation in the treatment of late-stage wrist tuberculosis. METHODS: From October 2015 to May 2019, 25 patients with late-stage wrist tuberculosis were treated using lesion removal, bone grafting, fusion, and external fixation. Among these patients, there were 14 males and 11 females, aged from 40 to 74 years old, with an average age of (60.72±8.45) years old. The duration of the disease ranged from 5 to 24 months, with an average of (11.52±7.61) months. There were 11 cases of left wrist tuberculosis and 14 cases of right wrist tuberculosis, with 5 cases accompanied by sinus formation. Postoperative regular anti-tuberculosis treatment was continued. Visual analogue score (VAS), inflammatory indicators, Gartland-Werley wrist function score, and upper limb function score were observed before and after treatment. RESULTS: All 25 patients were followed up for ranging from 12 to 36 months with an average of (19.7±6.3) months. At the latest follow-up, all wounds were healed satisfactorily, and there was no recurrence of tuberculosis or infection. VAS at one week before operation and three months after operation were (5.16±1.14) score and (1.68±0.80) score respectively. One week before operation and three months after operation, erythrocyte sedimentation rate (ESR) was (44.20±20.56) mm·h-1 and (14.44±1.14) mm·h-1, and C-reactive protein (CRP) was (12.37±7.95) mg·L-1 and (4.3±3.37) mg·L-1. The differences in all three data sets were statistically significant (P<0.01). According to Gartland-Werley wrist function scoring, the scores at one week before operation and one year after operation were (21.32±3.44) and (14.96±1.37) respectively, showed a statistically significant difference (P<0.01). According to the upper limb function score (disabilities of the arm, shoulder, and hand, DASH), the score was (70.52±7.95) at one week before operation and(28.84±2.30) at one year after operation. The difference was statistically significant (P<0.01). At the latest follow-up, no patient had a recurrence of tuberculosis. CONCLUSION: The short-term clinical efficacy of treating wrist tuberculosis with lesion removal, bone grafting, fusion, and external fixation is satisfactory.

A systematic review and network meta-analysis of outcomes after total wrist arthroplasty in inflammatory and non-inflammatory arthritis.

This systematic review analysed the available evidence on the clinical outcomes of total wrist arthroplasty (TWA) in patients with inflammatory and non-inflammatory arthritis. After screening, 12 studies met the inclusion criteria. They involved 359 patients with 378 TWA implants. The results showed that TWA significantly improved Disabilities of the Arm, Shoulder and Hand (DASH)/Quick-DASH scores and pain visual analogue scale scores in both arthritis groups compared with preoperative values. However, there was no statistically significant difference in the outcome scores between the two groups. Three studies reported Patient-Rated Wrist Evaluation (PRWE) scores, and TWA significantly improved PRWE scores in non-inflammatory arthritis but not in inflammatory arthritis, with no significant difference in postoperative outcome scores between the two groups. Although the included studies have limitations, the review suggests that TWA may be a successful treatment for wrist pain in individuals with either inflammatory or non-inflammatory arthritis. However, further high-quality trials are needed to confirm these findings.

Total wrist arthroplasty: commentary and opinions.

Total wrist arthroplasty (TWA) is gaining interest as a management option for wrist arthritis. This review article summarizes the current evidence base for TWA, focusing on the performance and survivorship of fourth-generation implants. These appear to offer satisfactory patient-reported outcomes and survivorship over the medium term, but heterogeneity between implants and patient populations complicates data interpretation. We discuss issues facing TWA practice, including surgical competency, volume, implant development and stewardship. We acknowledge the need for further research on this topic and highlight a number of questions that need answering.

Muscle redistribution technique for expressing motion intention in patients with wrist-level amputation.

This study reports the preliminary results of a technique for redistributing muscles at the wrist in the stump of hand amputees by suturing the tendons to the dermis. The technique has the potential to improve control of hand prostheses by detecting movement intentions.

Learning curves in Motec total wrist arthroplasty: an international cohort study.

We examined the learning curve of Motec total wrist arthroplasty (TWA) of six experienced surgeons in their first 30 cases. Three times more complications/revisions were encountered in the first half of the study compared with the second half. Motec TWA surgery should be concentrated in a smaller number of centres performing higher volumes.

Total wrist arthroplasty with the Freedom® prosthesis: a short-term follow-up.

We retrospectively reviewed our series of primary total wrist arthroplasty with the Freedom® prosthesis. The primary outcome measure was revision, and secondary measures included radiographic loosening, pain, complications, movement range, grip strength and patient-reported measures. We reviewed 12 implants in 11 patients (mean age 59 years, range 45-80) with a mean radiological and clinical follow-up of 2.7 and 3 years, respectively. One radial component failed to integrate and was revised at Day 84. Four carpal components demonstrated areas of lucency. There was a statistically significant reduction in pain, and total flexion-extension increased. Despite high patient satisfaction on a ten-point visual analogue scale score (mean 8.7 out of 10), the mean patient-rated wrist evaluation, Quick Disabilities of the Arm, Shoulder and Hand and Patient Evaluation Measure scores were 52, 55 and 53, respectively. The Freedom® implant reduced pain and preserved wrist movement in our patients; however, annual surveillance is recommended due to the high incidence of early carpal component lucency.Level of evidence: IV.

Long-term results of the AptisTM total distal radioulnar joint prosthesis after previous failed surgical procedures.

We present a prospective study with the results of ten Aptis total distal radioulnar joint replacements in patients who had one to five previous operations. The mean postoperative follow-up was 9.7 years (range 3-14.7). The mean postoperative range of motion of the wrist improved by 9° for extension, 15° for flexion, 10° for pronation and 14° for supination, achieving values equivalent to 88%, 78%, 97% and 88% of those of the non-operated hand. There were minimal changes in radial and ulnar deviations. Grip strength improved by 7 kg, pain decreased by 8 points, QuickDASH and Mayo wrist scores improved by 51 and 53 points, respectively. Two implants had radiolucency less than 1 mm. Serum titanium ion levels were slightly elevated in two patients. Three prostheses required revision surgery for heterotopic ossification, a prominent radial screw and a periprosthetic fracture. No prostheses were removed. Six patients returned to their former professional activities and four patients adapted their jobs.Level of evidence: IV.

Two arterial variations of the hand and wrist present bilaterally (persistent median artery and superficial dorsal branch of the radial artery): ultrasound findings.

PURPOSE: Arterial variations of the upper limb may bear high importance for many clinical procedures, including the use of flaps in plastic surgery. We present a feasible way for visualization and confirmation of presence of these variations. METHODS: All variations were detected by ultrasonography and confirmed by Color Doppler Imaging. Proper documentation was taken in order to present our findings. RESULTS: We report a case of a 19-year-old female who showed two concomitant arterial variations of the forearm and the hand bilaterally. These two variations were the persistent median artery and the superficial dorsal branch of the radial artery which both significantly contributed to the blood supply of the hand. All examinations were performed by the same investigator and all findings were reviewed by an experienced sonographist. CONCLUSION: An unusual arrangement of the arterial system can be easily detected. We present a feasible way to prevent iatrogenic injuries and increase utilization of anatomical variants knowledge in surgery by using ultrasound prior to planning surgical procedures.

Total Wrist Arthroplasty: An International Perspective.

Concerns about implant durability and technical difficulty continue to make total wrist arthroplasties a specialized procedure with a narrow scope of indications. As a result, more routinely performed total or partial wrist arthrodesis continues to maintain popularity over arthroplasty. However, wrist motion preservation is undoubtedly preferable for patients and current literature is trending to more favorable outcomes for total wrist arthroplasties. In the setting of the evolving role of wrist arthroplasties in clinical practice, it is important to focus on providing hand surgeons a practical approach to incorporating total wrist arthroplasty into the treatment toolbox available to them when treating patients with painful wrist arthritis.

Total Wrist Replacement Outcomes in the Asian Pacific Population - A Single-Centre Result.

Background: Total wrist replacement (TWR) is rarely done in the Asia-Pacific region. The aim of this study is to report the surgical outcomes and experience of TWR in patients with advanced arthritis. Methods: This is a retrospective review of all TWR patients in the Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Hong Kong, which is a university tertiary centre, from January 2004 to March 2023. Recorded demographic parameters include gender, age upon surgery, pathology, types of implants and follow-up period. The surgical outcome parameters include range of motion, grip strength, wrist function assessment, radiological and clinical complications and any related secondary operations. Postoperative X-ray and clinical notes were reviewed. All wrist function assessments were performed by specialised occupational therapists according to protocol. Results: The study included a total of 12 wrists of 10 patients, all Chinese-Asian, with a mean age of 61.4 years at surgery. Larsen grade V arthritis constituted 50% and grade IV 16.7% of the patients, amongst which 33% had volar subluxation. The mean follow-up period was 97.4 months (21-205 months). The mean grip strength was 64.2% of the unaffected side. The mean postoperative Disabilities of Arm, Shoulder and Hand (DASH) score was 41.12% and patient-rated wrist/hand evaluation (PRWE) score 18.0. Complication incidence was 16.67% for loosening, 8.3% for metallosis and 8.3% for infection. One patient required conversion to total wrist arthrodesis due to metallosis. No patient suffered from dislocation, periprosthetic fracture and infection. Conclusions: TWR is an effective and safe alternative to total wrist arthrodesis with comparable outcomes. Our series outcomes are satisfactory and in line with literature. With meticulous soft tissue release and balancing, volar subluxation can also be corrected and may not be a contraindication. Level of Evidence: Level IV (Therapeutic).

A Giant Lipoma in the Distal Forearm of a Cadaver.

OBJECTIVE: Lipomas are very common tumors which usually prefer the upper limbs and, depending on their size, may cause nerve compression, or may be asymptomatic. The current cadaveric report describes a giant lipoma in the distal forearm area. CASE REPORT: A large mass (5.1 × 3.2 × 1.6 cm) was identified on the palmar surface of the distal forearm, during dissection of a 63-year-old male cadaver. The mass caused anteromedial displacement and flattening of the median nerve (MN). Despite the lack of information about the subject's medical history, MN compression was assumed on the basis of the lipoma's size, its vicinity to neural structures, and the MN displacement and flattening. CONCLUSION: The enlarged distal forearm lipoma, located adjacent to the carpal tunnel, displaced and flattened the MN. The cadaveric finding described is clinically relevant for both differential diagnosis and surgical treatment of carpal tunnel syndrome.

Revision of Motec Total Wrist Replacement in the Second Metacarpal.

Wrist arthroplasty is becoming more commonplace, with various implant choices available. The Motec (Swemac Orthopaedics AB, Linköping, Sweden) cementless ball-and-socket system is being increasingly utilised and is designed for the distal component to be implanted into the third metacarpal. However, distal component failure is a recognised complication. We outline our experience with the revision of this component into the second metacarpal. This technical note is presented through our experience of two patients who underwent revision arthroplasty for the management of peri-prosthetic fracture of the third metacarpal. This technique has demonstrated a safe and viable solution to this complication, achieving good anatomical centre of rotation, function, range of movement and patient satisfaction. Level of Evidence: Level V (Therapeutic).

[Effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with wrist electric burn].

Objective: To explore the effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with severe wrist electric burn. Methods: A retrospective observational study was conducted. From January 2017 to December 2020, 4 patients with wrist high-voltage electric burn admitted to the Department of Burns of the First People's Hospital of Zhengzhou and 4 patients with wrist high-voltage electric burn admitted to the Department of Hand Surgery of Beijing Jishuitan Hospital met the inclusion criteria, including 6 males and 2 females, aged 12 to 52 years. They were all classified as type Ⅱ wrist high-voltage electric burns with median nerve defect. In the first stage, the wounds were repaired with free anterolateral thigh femoral myocutaneous flap. In the second stage, the free gracilis muscle flap combined with sural nerve transplantation was used to reconstruct the digital flexion and sensory function of the affected hand in 3 to 6 months after wound healing. The cut lengths of muscle flap and nerve were 32 to 38 and 28 to 36 cm, respectively. The muscle flap donor area and nerve donor area were both closed and sutured. The survival condition of gracilis muscle flap and sural nerve, the wound healing time of recipient area on forearm, the healing time of suture in muscle flap donor area and nerve donor area were observed and recorded after operation, and the recovery of donor and recipient areas was followed up. In 2 years after operation, the muscle strength of thumb and digital flexion and finger sensory function after the hand function reconstruction were evaluated with the evaluation criteria of the hand tendon and nerve repair in the trial standard for the evaluation of functions of upper limbs of Hand Surgery Society of Chinese Medical Association. Results: All the gracilis muscle flap and sural nerve survived successfully after operation. The wound healing time of recipient area on forearm was 10 to 14 days after operation, and the healing time of suture in muscle flap donor area and nerve donor area was 12 to 15 days after operation. The donor and recipient areas recovered well. In the follow-up of 2 years after operation, the muscle strength of thumb and digital flexion was evaluated as follows: 4 cases of grade 5, 3 cases of grade 4, and 1 case of grade 2; the finger sensory function was evaluated as follows: 4 cases of grade S3+, 2 cases of grade S3, and 2 cases of grade S2. Conclusions: For patients with hand dysfunction caused by severe wrist electric burn, free gracilis muscle flap combined with sural nerve transplantation can be used to reconstruct the digital flexion and sensory function of the affected hand. It is a good repair method, which does not cause great damage to thigh muscle flap donor area or calf nerve donor area.

[Clinical effect of the giant deep inferior epigastric artery paraumbilical perforator flap in repairing the circular high-voltage electric burn wounds on the wrist].

Objective: To investigate the clinical effect of the giant deep inferior epigastric artery paraumbilical perforator flap in repairing the circular high-voltage electric burn wounds on the wrist. Methods: A retrospective observational study method was used. From September 2016 to October 2021, thirteen male patients (aged 20-43 years) with annular high voltage (10-100 kV) electrical burns on the wrist were admitted to the Beijing Jishuitan Hospital. At the early stage after injury, the patient's wrist was subjected to incision, tension reduction and debridement, with the wound area after debridement being 27 cm×16 cm-32 cm×19 cm; in 12 patients with vascular injury, the radial or ulnar artery was reconstructed by great saphenous vein transplantation, with the length of 15-25 cm; the wrist wound was repaired by free transplantation of the deep inferior epigastric artery paraumbilical perforator flap (if the wound was giant, the lower abdominal flap carrying other perforators was used), with the area of 30 cm×19 cm-35 cm×20 cm. The donor site was repaired by direct suture+skin grafting or relay flap transplantation. After surgery, the survival of flap in recipient area, as well as survival of the skin or flap in donor site were observed. During follow-up, the appearances of the flap in recipient area and the recovery of hand function, as well as the healing of donor site, occurrence of abdominal wall hernia, and scar in skin graft area were observed. Results: After surgery, all the 13 patients' paraumbilical perforator flaps survived. Among them, 3 patients had subcutaneous fat necrosis at the distal end of the wrist flap, and the wound had mild infection, which healed after re-expansion and dressing change. All the skin grafts in the donor site of 10 patients survived, and the flaps in the donor site of 3 patients survived well. The patients were followed up for 6 months to 3 years. The flaps in recipient area were in good shape, 8 cases had partial recovery of hand function, and 5 cases had loss of finger flexion function; the donor site of abdominal flap healed well with no abdominal hernia occurred, and the skin graft site had no obvious scar hyperplasia and was soft in texture. Conclusions: Early vascular reconstruction after injury, together with free transplantation of the giant deep inferior epigastric artery paraumbilical perforator flap are effective in repairing circular high-voltage electrical burn wounds on the wrist.

Role for Wrist Hemiarthroplasty in Acute Irreparable Distal Radius Fracture in the Elderly.

Volar locking plates for distal radius fracture (DRF) in the elderly may show complications in the most comminuted osteoporotic cases. The authors provide criteria for DRF in elderly that may not be amenable to volar plating ("irreparable DRF") and review the current results of a preliminary series of wrist hemiarthroplasty for these injuries. Between 2011 and 2019, 28 wrists with acute irreparable intra-articular DRF were treated with wrist hemiarthroplasty (96% female, mean age 79 years). A total of 17 wrists with a mean follow-up of 32 months were reviewed. At follow-up, mean visual analog scale (VAS) pain was 1/10, mean forearm rotation arc was 148°.